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General NPI Number Information
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NPI Number | 1477665065
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Entity Type | Individual
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Provider Name | JASON KENNETH COLEMAN DMD
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Gender | Male
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3964 GOODMAN RD E SUITE 128
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City | SOUTHAVEN
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State | MS
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Zip | 38672-8761
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Country | US
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Telephone | 662-893-7337
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Fax | 662-893-7881
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Provider Business Mailing Address
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Address Line | 4036 ROBERTSON GIN RD
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City | HERNANDO
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State | MS
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Zip | 38632-8228
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Country | US
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Telephone | 662-429-3419
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 3112-99
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License Number State | MS
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